The cardiovascular effect of smoking bans in Europe 

There were no riots in public bars, few “patrons” complaining that their cafés were empty. And those who couldn’t resist a cigarette simply stepped outside for a while. But there were protests.
The most vocal complaint of the pro-smoking, anti-prohibition lobby is that the studies which seem to validate our smoking bans – whether local or national – are no better than pseudo science, or “junk science” as their protest placards would have us believe. Indeed, even one of the bigger studies of this kind – the Scottish StopIt study from Pell and colleagues published in the New England Journal of Medicine last year – was described in a BBC review as “over-hasty and over-confident research” when it was first presented at a conference. 

The issue which - for some - reduces these studies to junk is causation, and with it the basic epidemiological conundrum of when statistical association becomes an unequivocal cause and effect. For critics of the smoking bans, none of the studies reported prove causation (that a smoking ban actually lowers the incidence of heart disease), and are so replete with confounding that any valid conclusion is impossible.

Yet the fact is that every study so far reported on the effect of smoking bans does indeed show a lowering of hospital admissions or death from CHD.

• In February last year the French authorities announced a 15% decrease in emergency admissions for AMI just one year after the public ban on smoking came into effect.
• Similar results were reported from Italy when researchers in Rome found an 11.2% reduction of acute coronary events since a January 2005 smoking ban among patients under 65.
• Researchers from Ireland, where a public smoking ban was introduced in 2004, found a reduction of 11% in admissions with acute coronary events in the year following the ban, which was sustained through the following year.

The Scottish StopIt study, which monitored the effects of legislation introduced in March 2006, reported a 17% reduction in hospitalisations for ACS - as compared with a 4% reduction in England, where no such legislation was in place at the time, over a ten-month study period. The investigators noted that this decrease was much greater than the underlying trend (there was a mean annual decrease of 3% in ACS admissions during the decade before the study). They also reported that cotinine assays in non-smoking adults in Scotland confirmed a reduced overall exposure to smoke of 42%, a reduction not dissimilar to the 47% reduction reported in New York after their enactment of smoke-free legislation.

Similarly, a recent meta-analysis of eight studies on the effects of smoke-free legislations (four from US states, two from Italy and one from Canada and Ireland) concluded that they yielded “an immediate 19% reduction” in AMI admission rates “associated with these laws”.

Total bans on smoking in all enclosed public places and workplaces in Europe, including bars and restaurants, are so far enforced only in Ireland and UK. Legislation in Italy, Malta, Sweden, Latvia, Finland, Slovenia, France and the Netherlands allows for special enclosed smoking rooms.

Professor Erika Froelicher from the University of California, San Francisco, who spoke at a Symposium on smoking cessation last Sunday, says that in Europe and all states of the USA the smoking bans have been “highly successful,” but not everywhere in the world. “It’s a matter of enforcement,” she says. “In those parts of the world where smoking bans are ignored and not enforced, they’re having little effect.”

For Professor Froelicher, an epidemiologist and clinical nurse specialist, the enforcement of smoking bans by legislation should be part of a range of measures designed to discourage smoking and exert peer pressure that it’s simply a bad habit. As part of that range, raising the price of cigarettes – mainly through taxation – “is the single most successful way,” but she also emphasises the importance of personal intervention and the role of nurses and physicians. “Healthcare professionals do not show sufficient inclination to intervene,” she says. “It’s relatively straightforward, and counseling is an important option.”

For her part, Professor Jill Pell from Glasgow University, first author of the StopIt study, has recently concluded (in a June review for the journal Heart) that “there is increasing evidence that [smoke-free legislation] reduces the risk of cardiovascular disease” and that “we have good reason to believe that the early beneficial effects will be maintained in the longer-term and may even increase”.